Advance Healthcare Statement

The Advance Care Planning Group of Los Angeles

Medical treatment is intended to preserve life and improve its quality, yet when misdirected it can cause pain and suffering. Misdirected treatments may also reduce dignity and comfort at the end of life. In contrast, optimal healthcare involves planning for all stages of life to ensure care is consistent with each patient's values and goals, while adhering to medical standards. To promote our common goals of respecting individual values and reducing unnecessary suffering at the end of life, after extensive discussion our health systems are united in recommending₁:

1. Advance Care Planning should be standard medical care in our community and should be encouraged for all adults. Such planning involves discussing and documenting patient values, preferences, and goals to help guide healthcare professionals and families in providing appropriate future care. Physicians and members of the healthcare team₂ should encourage every patient with a terminal illness₃ who does not yet have an advance directive to engage in Advance Care Planning without delay — regardless of age.
2. Medical systems and healthcare providers should facilitate early access to palliative and other supportive services for all patients with chronic and progressive illnesses, when such services are available. Early education about and timely access to hospice services are essential for easing the dying process for patients with terminal illness₃.
3. Physicians should advise patients and families on the likely benefits and burdens of potential therapies and whether they are consistent with a patient’s known values and goals₄. These discussions should disclose whether any treatments under consideration may deprive the person of life closure (the ability to say "forgive me," "I love you" or "goodbye") or preclude a peaceful death.
4. Shared decision-making is fundamental to optimal quality of care at the end of life. Physicians should engage in this process with patients or their legally recognized agent, while understanding that they are not obliged to offer or provide medically non-beneficial treatment₅. Medical staffs, medical groups, or healthcare systems should provide policies, such as those recommended by the California Medical Association₆, to guide physicians and healthcare teams when such care is requested. The healthcare team’s interactions with patients and families should demonstrate respect for all views and help guide the parties to a resolution consistent with applicable medical standards and laws.

References

1. Guidelines must be used in the context of clinical judgment and will not apply in all situations.
2. Physicians are uniquely positioned to take a leadership position in both providing medical expertise and in facilitating the team of other professionals who are integral to this process (nurses, social workers, chaplains).
3. Terminal illness is defined as any disease affecting one or more organs whose progression is not preventable, and commonly leads or contributes to death or manifest deterioration (mental or physical) within a predictable timeframe. End-stage terminal illness often includes, though is not limited to, stage 4 disease of the heart or lungs, stage 4 cancer, or advanced dementia, as defined by: New York Heart Association (NYHA), Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria, National Comprehensive Cancer Network (NCCN), or Cognitive Performance Score (CPS). Patients with end-stage terminal illness would be expected to have a life expectancy of less than 6 months.
4. When a patient has not documented their expressed goals, values, and preferences, and cannot participate in decision-making, a legally recognized healthcare decision maker may assist by describing their understanding of the patient’s goals, values and preferences.
5. In patients with late-stage terminal illness, use of interventions such as renal dialysis, intravenous feeding, gastric food feeding, artificial ventilation, cardiopulmonary resuscitation or admission to an intensive care unit are generally non-beneficial and may cause an increase in pain and suffering (i.e. harm). Decisions not to comply with a patient or legally recognized healthcare decision maker’s request for medically non-beneficial treatment should be undertaken in accordance with California probate code sections 4734-4736.
6. CMA Model Policy: Responding to Requests for Non-Beneficial Treatment.